Disclosure and Release

DISCLOSURE AND RELEASE

In connection with my application for employment, I understand that a background report may be requested at will by (Client). The investigative consumer report will be requested from Rexus Corporation, a Consumer Reporting Agency. This investigative report may contain information as to my character, general reputation, personal characteristics or mode of living. This report may include such information as: education, verification of current and former employment, driving record, credit, bankruptcy proceedings, criminal records, etc., from federal, state, and other agencies which maintain such records.

As set forth in the Fair Credit Reporting Act, I have the right to request from (Client), and the report provider, upon proper identification and written request, a copy of the consumer report as well as a written summary of my rights under the Fair Credit Reporting Act.

The information requested will be used in compliance with the Fair Credit Reporting Act and/or any other applicable federal or state laws. I authorize any party, institution, school, employer or agency contacted by (Client). or its authorized representatives, to furnish the above-described information. I release from liability the agents, employers, and all other persons providing information. I hereby authorize procurement of the background report.
Applicant Name:*
Date*
MM slash DD slash YYYY
Applicant: Please complete the following for proper identification purposes
Name:*
First Middle Last
Social Security Number:*
Date of Birth:*
MM slash DD slash YYYY
List all other last names used and the years the names were used:
Last name used: Years name was used:
List ALL addresses for past 10 years
Current Address City County State/Zip How Long?
Drivers License Number:*
State of Issue:*
For California, Minnesota or Oklahoma applicants only, if you would like to receive a copy of the consumer report, if one is obtained, please check this box:
For California, Minnesota or Oklahoma applicants only, if you would like to receive a copy of the consumer report, if one is obtained, please check this box:
- California, Minnesota or Oklahoma applicants
For California applicants only, if public record information is obtained without using a consumer reporting agency, you will be supplied a copy of the public record information unless you check this box waiving your right to obtain a copy of the report:
For California applicants only, if public record information is obtained without using a consumer reporting agency, you will be supplied a copy of the public record information unless you check this box waiving your right to obtain a copy of the report:
- California applicants only
Do you want to receive our newsletter?*
- Yes
- No

Last name used:	Years name was used:

Current Address	City	County	State/Zip	How Long?

DISCLOSURE AND RELEASE

Applicant: Please complete the following for proper identification purposes